ABSTRACT The overall aim of this R34 proposal is to examine the feasibility, acceptability, and short-term outcomes associated with an innovative service delivery model to increase adherence to extended-release naltrexone (XR- NTX) during the transition from jail to the community for rural women with opioid use disorder (OUD). The significance of this study is grounded in the public health crisis associated with the opioid epidemic in rural Appalachia, the increased vulnerability of rural women with OUD, and the dearth of available and accessible evidence-based treatment in the region. This R34 has potential to make a significant contribution to the OUD treatment field by advancing knowledge on innovative service delivery models to increase access to evidence- based treatment to reduce high-risk opioid use and related health disparities among hard-to-reach, high-risk, underserved populations. The study will be accomplished through two specific aims: (1) Adapt XR-NTX services for use in community supervision (P&P) offices to increase adherence during re-entry from jail for rural women with OUD. (2) Examine feasibility, acceptability, and short-term outcomes of XR-NTX adherence and relapse to opioid use through a small pilot trial with 60 rural women with OUD. The pilot trial will include OUD screening, medical evaluation, XR-NTX initiation prior to jail release, and random assignment to one of two community re- entry treatment models to receive on-going XR-NTX injections in the community after release in either: (1) A local rural P&P office (n=30), or (2) Services as Usual (n=30, referral to a community clinic). If this study establishes feasibility of this innovative community-based treatment model for XR-NTX in a rural, underserved area, findings will be used to develop an R01 application to test the approach in a larger RCT during community re-entry from jail among high-risk rural women with OUD in Appalachia. The long-term goal of this research is to increase access to evidence-based treatment for OUD among high-risk, underserved populations.